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Montagne et al. Mini-invasive Surg 2020;4:17 I http://dx.doi.org/10.20517/2574-1225.2019.74 Page 5 of 11

Main results of meta-analysis and systematic reviews according to lobectomy performed by
RATS, VATS, or open surgery
[13]
Ng et al. published the latest and most extensive systematic review and meta-analysis in 2019 comparing
VATS to open thoracotomy, VATS to RATS, and also multiport and uniport VATS. They included 138 studies
and 7 randomized controlled trials with 369,793 patients. They analyzed short-term outcomes such
as complications, mortality, and oncologic quality criteria with lymph node dissection and long-term
outcomes. They also analyzed functional data with pain, quality of life, pulmonary function, and cost-
effectiveness. They reported a lower complication rate with VATS lobectomy than with open lobectomy (OR
0.64, 95%CI 0.59-0.71, P < 0.001), and no difference in mortality rate (OR 0.78, 95%CI 0.56-1.07, P = 0.12).
The rate of nodal upstaging was lower with VATS than with open surgery (OR 0.71, 95%CI 0.58-0.87), with
no difference in the number of lymph nodes resected (P = 0.18) or nodal stations explored (P = 0.49). They
found no difference in the rate of nodal upstaging between VATS and RATS (OR 1.02, 95%CI 0.85-1.22, P
= 0.87). Length of hospital stay was shorter after VATS than open surgery, −1.9 days (95%CI −2.25 to 1.54,
P < 0.001), but there was no difference between VATS and RATS, −0.16 days (95%CI 0.81-0.48, P = 0.62).
Concerning long-term outcomes, five-year overall survival was improved after VATS lobectomy compared
to open lobectomy (OR 1.35, 95%CI 1.17-1.56, P < 0.0001), with no difference observed in disease free
survival (OR 1.15, 95%CI 0.94-1.40, P = 0.18). There was no difference in five-year overall survival between
VATS and RATS (OR 0.79, 95%CI 0.47-1.33, P = 0.38) or in five-year disease free survival (OR 0.71, 95%CI
0.44-1.14, P = 0.16). The main results of the reports analyzed in this article are presented in Table 1.

[14]
O’Sullivan et al. published in 2018 the first systematic review and meta-analysis and concluded that
RATS lobectomy significantly improved the short-term outcomes of patients more than VATS or open
lobectomy. After RATS lobectomy, compared to open lobectomy, there was an improvement in short-term
outcomes, with fewer complications (OR 0.67, 95%CI 0.58-0.76, P < 0.00001), lower 30-day mortality (OR
0.53, 95%CI 0.33-0.85, P = 0.08), and shorter length of hospital stay with weighted mean difference (WMD)
of −1.4 days (95%CI −1.96 to 0.85, P < 0.00001), but longer operative times with WMD of 65.56 min (95%CI
53.66-77.46, P < 0.00001). After RATS lobectomy, compared to VATS lobectomy, there was a lower rate of
30-day mortality (OR 0.61, 95%CI 0.45-0.83, P = 0.001), with longer operative times with WMD of 4.98 min
(95%CI 2.61-7.36, P < 0.001).

[29]
Adams et al. in 2014 published one of the first retrospective multicenter comparisons of short-term
outcomes after lobectomy performed by RATS, VATS, or open surgery and concluded that RATS was
equivalent to VATS for all intraoperative and postoperative outcomes, but allowed better short-term
outcomes compared to open surgery. Their main results were lower rates of postoperative blood transfusion
(0.9% vs. 7.8%, P = 0.002), fewer air leaks of more than five days (5.2% vs. 10.8%, P = 0.05), shorter duration
of chest tube placement (3.2 days vs. 4.8 days, P =< 0.001), and shorter length of stay (4.7 days vs. 7.3 days,
[30]
[31]
[15]
P < 0.001). Agzarian et al. , Kent et al. , and Rajaram et al. concluded that RATS was not superior
to VATS for perioperative outcomes. Compared to open surgery, RATS was found superior with fewer
[32]
perioperative outcomes .
[14]
Until the publication of O’Sullivan et al. , systematic reviews and meta-analyses [32-36] found small
significant differences in short-term outcomes between RATS and VATS lobectomy or no difference
between these two minimally invasive surgical approaches.

Minimally invasive approaches for locally advanced NSCLC
Petersen et al. in 2006 were among the first to demonstrate that VATS lobectomy was safe and feasible
[37]
for selected patients with NSCLC who had received induction chemotherapy or chemoradiotherapy. They
reported short-term outcomes with no increase in the number of adverse events after VATS resection and
[38]
with the same oncologic efficacy. Yang et al. reported a propensity score matched analysis, in which
survival of patients operated by VATS after induction chemotherapy with or without radiotherapy was